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' - �,- <br /> FOR OFFICE USE: FOR OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT <br /> (Complete in Triplicate) Permit No... ---- ------ <br /> ------------------------ -------------------------------- - <br /> -------------------------------------------------- - This Permit Expires 1 Year From Date Issued Date Issued__-. <br /> { <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct and install the work herein described, <br /> This application is made in compliance with County Ordinance No, 549 and existing Rules and Regulations: <br /> JOB ADDRESS/ <br /> s <br /> LOCATION-- Q----- + ------ -a'Z.._--------------- -----------------CENSUS ------- -- ------------ --- <br /> Owner's Name._.__.----Ds_----- --- o �-- Phone <br /> ---- -- -------------------------------------------------------------------------------------------- <br /> Address------ --...W------- �' tom ---------- -------- --- ----------City- r-cx`- y----------------Zip-- --------------------- r <br /> Contractor's Name--R.- A ------ -. jk4�.Yv_1.,5__------ ,``,t--` ---- 'L'icense #-a-x_.8._1__9-� <br /> ---Phone__?(SA.'--y3-t7.Q__. <br /> Installation will serve: li:esidence ❑ Apartment House❑ Commercial ❑ Trailer Court ❑ <br /> �. ..Motel ----------------- __ _ <br /> g 3- 9 <br /> Number of.libin units__________ ____ Number.of bedrooms Pther <br /> a Grinder____.__-_. Lot Size___ _.____Z_ --- �� =___._.-_____.__._ <br /> Water Supply: Public System and name__________________________',-'_ ------ ----_------ -Private <br /> i' <br /> _ --------------------------_-=-.----- - <br /> Character of;soil to a.depth of 3 feet: Sand [ Silt F-r'Clay ❑ Peat Ej Sandy Loam ❑ Clay Loam [X + t t <br /> Hardpan ❑ ^­Adobe.❑ - Fill Material-. ________If yes,,type--------_____ ----------------- 7 t 4 <br /> r <br /> (Plot plan, showing size of lot, location of system in relation to-wells, buildings, etc..must be placed on'reverse side.) ! <br /> NEW INSTALLATION: {No septic tank or seepage pif permitted if public sewer is available within 200 feet,} <br /> TREATMENT [ SEPTIC TANK [vj� Size--___ Q� {�-�' _ _._____°___ fDepth ' [ <br /> + <br /> 4 ---------------Liquid ------- ' <br /> PACKAGE TR Ca pa city-h_�d 1 <br /> i <br /> aterial_. -f31 ?_Cr[_Nlo.,Compartments <br /> -- Len th of each Foundation`- _-- _ p. Line_ -��------ <br /> Distance.to nearest: Well... 0.6 t___ _ t _ <br /> LEACHING.LINE [ No. of Lines.--.-_ g <br /> i g ; <br /> h line - t � - .Total Len th. Z, ' <br /> 'D' Box- __1___.__T a Filter Material—Ni-,�' .-__ e th Filter Material_.____i i <br /> i --.--Type p i f 1 nv f <br /> I " D � V_-Foundation__200._ k - Pro ert Line__. <br /> SEEPAGE PIT [ ] Depth ...:...........Diameter.-_--' T `* � -�_ r, +' t <br /> Distance to nearest:Well___ �._ <br /> . .----___--.Number---"--- -- ------____-- _ �.' ock Filled Yes ❑ i No ❑ <br /> R <br /> :. Water Table Depth -- '�, -----'`.Rock Size--------- ' <br /> ----------- ---------------- <br /> ,Distance to nearest: Well--- ----- --------- ----------Foundation---------------- ---- ----Pr bp. Line--------- <br /> REPAIR/ADDITION <br /> ------ `REPAIR/ADDITION (Prev. Sanitation Permit#----- ----- <br /> __ De <br /> --------- -- -------- ------------ -_ �- - -- <br /> ---- <br /> ------- <br /> _________ <br /> Septic Tank (Specify Requirements} ---------•------- --- = --------- ----- ------------ ----- - ----------------------_.----- - i 1 :`--- -.- <br /> - ------- <br /> Disposal Field (Specify Requirements)-------------- <br /> - - ------------- <br /> ------------------- ------------ <br /> 1 <br /> -----5-----"`------ -_---------------- - 1 <br /> (Draw existing and required addition'on reverse side) <br /> hereby certify that I have prepared this application and that the work will be--done:in-accordance with,San Joaquin County <br /> Ordinances, State Laws, and Rules and Regulations_ of the San Joaquin Local Health District. Home owner or licensed agents <br /> signature certifies the following: + ' <br /> "I certify that in the performance of the work for which this permit is issued, I shall not employ any person in sucli manner as <br /> to become s b[ect to Work an-s Compensation laws. of California." ` <br /> Signed i /-1 ��'/- run!r�! - ------Owner <br /> Y ` <br /> BY------- t,-- --- -- ------- -- ------ ---------Ti <br /> tl e f � ,. # <br /> other than owner} <br /> t <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY- i - = DATE. �= <br /> C <br /> DIVISION OF LAND NUMBER_ ----'------------------------------------------------ -- ---------- -- -------------'----------- DATE.__.I-------------------------- ----------- <br /> ADDITIONAL, COMMENTS ---- -- ------------------------------------ - <br /> ---------------------------------- -------------------------------------------- ------------------- ---- - <br /> `� ------------- -------- -- <br /> ------------------------------------------------ �_:'------------ - ------- -- -- -- ----------- -----------------/ ----- - -- <br /> Final Inspection by— r Date.-- 1 = ............. <br /> { <br /> EK 13 24 - SAN JOAQUIN LOCAL HEALTH DISTRICT F&S 21677 REV.Z/76 3M <br />